INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 12, 2011 licensure renewal inspection. The follow-up inspection was conducted on June 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gateway Erie was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Ten client records were reviewed on January 11-12, 2011. Six client records were reviewed as inpatient client records. Three client records were closed and were required to include documentation of the facility's attempt to follow up on the clients. Per facility policy, follow up is to be completed at 30 days. The facility did not document follow up in client record #6.
Client # 6 was admitted on September 28, 2010 and discharged on October 26, 2010. Follow up was to be completed by November 26, 2010. There was no documentation that a follow up had been attempted or completed as of January 12, 2010.
The facility director was interviewed on January 12, 2011. No additional information or documentation was offered for review.
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Plan of Correction
An E-mail was sent on 7/13/11 to the Research Department of Gateway Rehabilitation Center to provide this sattelite with documentation of follow up for filing in the Patient Record. The Program Director will review compliance with this process in one month on 8/15/11. If this POC is not rectified at that time the Program Director will involve the Divisional Manager and the Vice President of Therapy Programs. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a psychosocial evaluation in six of six outpatient client records.
The findings include:
Thirteen client records were reviewed on June 14, 2011. Six client records were reviewed as outpatient records. Per facility policy, psychosocial evaluations are to be completed by the third session. Six outpatient client records reviewed required documentation of a psychosocial evaluation. There was no documentation that a psychosocial evaluation was completed per facility policy in client records # 8, 9, 10, 11, 12 and 13.
Client # 8 was admitted on March 18, 2011. The psychosocial was to be completed by the third session which occurred on April 7, 2011. There was no documentation that a psychosocial evaluation had been completed as of June 14, 2011.
Client # 9 was admitted on April 4, 2011. The psychosocial was to be completed by the third session which occurred on April 7, 2011. There was no documentation that a psychosocial evaluation had been completed as of June 14, 2011.
Client # 10 was admitted on May 4, 2011. The psychosocial was to be completed by the third session which occurred on May 11, 2011. There was no documentation that a psychosocial evaluation had been completed as of June 14, 2011.
Client #11 was admitted on May 9, 2011. The psychosocial was to be completed by the third session which occurred on May 12, 2011. There was no documentation that a psychosocial evaluation had been completed as of June 14, 2011.
Client #12 was admitted on April 19, 2011. The psychosocial was to be completed by the third session which occurred on April 21, 2011. There was no documentation that a psychosocial evaluation had been completed as of June 14, 2011.
Client #13 was admitted on May 16, 2011. The psychosocial was to be completed by the third session which occurred on May 19, 2011. There was no documentation that a psychosocial evaluation had been completed as of June 14, 2011.
An interview with the facility director on June 14 at 3:30 P.M. confirmed the psychosocial evaluations were not documented for the above mentioned client records.
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Plan of Correction
In a meeting with the Out Patient Therapist on July 1,2011 The Program
Director presented the deficiency and the following course of action. The Therapist will utilize the standard Gateway format for a Pschyosocial Evaluation. Examples of documents were presented with the clear expectation of the necessity to utilize this format.The supervisoy training was conducted as to the expectations of content.The Therapist will type the Psychosocial Evaluation. Compliance will be monitored by the Program Director during routine monthly reviews. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of personnel records and interviews with the human resource director and the facility director, the facility failed to document follow-up information per facility policy in two of two client records.
The findings include:
Eleven client records were reviewed on January 4-5 and 20-21, 2010. The human resource director was interviewed on January 5, 2010 and the facility director was interviewed on January 20, 2010. Four client records were reviewed as outpatient client records. Policy states the the client will receive follow up contact at 1, 3, 6 and 12 months after discharge. Two outpatient client records were required to have follow-up information completed. The facility did not document follow up information in client records # 10 and 11.
Client # 10 was admitted on October 26, 2009 and discharged on December 2, 2009. Follow up contact was due on January 2, 2010. There was no documentation that follow up contact had been attempted or made.
Client #11 was admitted on August 14, 2009 and discharged on September 17, 2009. Follow up contacts were due on October 17, 2009 and December 17, 2009. There was no documentation that follow up contacts had been attempted or made.
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Plan of Correction
An E-mail was sent on 7/13/11 to the Research Department of Gateway Rehabilitation Center to provide this satelite with documentation of follow up for filing in the Patient Record. The Program Director will review compliance with this process in one month on 8/15/11. If this POC is not rectified at that time the Program Director will involve the Divisional Manager and the Vice President of Therapy Programs. |